According to an investigation by the House Committee on Oversight and Reform into health plans and pharmacy benefit managers (PBMs), more than 30 birth control products have cost-sharing requirements or coverage exclusions that violate the Health Care Act. available medical care.
Findings revealed this week in a staff reportshow that insurers and PBMs are not complying with the Affordable Care Act (ACA), which requires issuers and health plans to cover contraceptives approved by the US Food and Drug Administration (FDA) without requiring patients to pay out of their own out-of-pocket, also known as co-pays.
The investigation also found that companies denied requests for exemptions an average of four or more times out of ten, creating barriers to access to birth control, according to news release issued on Tuesday.
“After the cancellation of the final decision of the Supreme Court Roe v. Wade, the ability to decide if and when to get pregnant has never been more important,” said Representative Carolyn B. Maloney, chairwoman of the Oversight and Reform Committee, in a news release.
The investigation is the first congressional report on contraceptive coverage in the private health insurance market. In May, the Committee requested information from five insurers: UnitedHealth, Hymn, Etna, Swan and Humana and four pharmacy managers: CVS Caremark, Express scripts, OptumRx and Prime Therapeutics as part of the investigation.
“The Biden-Harris administration recently issued important guidance on expanding contraceptive coverage under the ACA, and I urge the administration to update its guidance to address the issues identified in this report,” Maloney said.
The report found excessive costs for several products. For example, the companies reported cost-sharing obligations of up to $178 per month for certain non-pill contraceptives, such as the Twirla patch, and approximately $218 per month for certain birth control pills.
Cost-sharing practices disproportionately affect low-income patients, according to the report. Four of the 17 products are non-pill products, which are disproportionately used by lower-income and non-white patients.
“Unfortunately, affordability is often determined by a person’s specific health insurance, which (in the case of private insurance) often depends on the person’s job,” said Bethany Corbin, senior counsel at Nixon Gwilt Law, which advises on femtech and health innovation. companies and owners Legal Femtech Podcast.
Corbyn said the report shows how “money – not medical necessity – can be the driving factor” rather than medical advice and the needs of patients. “I am grateful for the light that is finally being shined on the disproportionate influence health plans and PBMs have on women’s reproductive choices,” Corbin said.
When a patient tries to request an exemption so they can pay less out-of-pocket, they encounter significant delays, up to 15 days, the report found. One company reported delays of up to 15 days to process exemption requests, and two companies asked that providers document previous medications a patient had tried unsuccessfully for that patient to receive an exemption.
The staff report recommended that the Department of Health and Human Services, the Department of Labor, and the Department of the Treasury issue guidance clarifying that all FDA-approved contraceptives that do not have a therapeutic equivalent must be covered without cost-sharing as part of each plan or formulary.
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